1. Medicaid Funding for Respite
David Buchanan MD
Head, Section of Social Medicine
Stroger Hospital of Cook County / Rush University
National Respite Providers Network – Houston 2005

2. Why talk about Medicaid?
Medicaid – It’s where the money is!
Multi-billion dollar budget in many states
Second only to education in state budgets
Medicaid funds healthcare for low income people
Bears the costs of an inefficient health system
They need us to save them money

3. Medicaid Funding for Respite
The Medicaid Program
Strategies for Funding
Illinois’ Effort
Updates from other states

4. The Medicaid Program
Centers for Medicare and Medicaid Services – “CMS”
Medical Services to Low Income and Disabled
Generally Fee for Service
Federal Medicaid Law specifies
Basic requirements
Optional components
States choose
service and eligibility options to cover
how much it will pay for each service

5. Medicaid: Who pays for it?
State pays the bills
Federal Government reimburses states
Federal Financial Participation varies 50-83%
Based on state’s per capita income
Covers services in Medicaid Law or in a Waiver

6. Mandatory Eligibility
“Mandatory Categorically Needy”
Based on Eligibility for AFDC in 1996
Women with Children
Pregnant Women
Low Income Children
Blind
SSI recipients

7. Optional Eligibility Optional Categorically Needy & Medically Needy
Expanded income limits
Breast and Cervical Cancer
Tuberculosis
Low Income Elderly

8. What does it pay for? Nursing home care
Medical, psychiatric, & substance abuse treatment
Medications
Case management
A range of other services (state specific)

9. Medicaid Waivers States can ask for Fed match for programs which:
Are within the spirit of the Medicaid Program
Are Cost Neutral to the Federal Government
States Apply to CMS
CMS decides based on:
Merits of program
Cost Neutrality
Politics

10. Medicaid Funding for Respite
The Medicaid Program
Strategies for Funding
Illinois’ Effort
Updates from other states

11. Strategies for Medicaid Funding
Bill Medicaid for Services they already cover
State Funded Programs
Apply for a 1115 Waiver (Federal Match)

12. Bill Medicaid for Covered Services
Outpatient Visits (all states)
Targeted Case Management (state option)
Skilled Living Facilities (state option)
Consider Partnering with a FQHC
Higher re-imbursement rates
Medicaid Billing system in place
Reimbursements are low
Much of what we call respite care isn’t covered

13. State Funded Respite Program
Doesn’t require a waiver / permission from Feds
Costs of waiver application may be > the return
More flexibility (eligibility)
Eligibility
Per-diem payment possible
Example: Washington State
Challenges: Novel state program / Tight budgets

14. Apply for a 1115 Waiver (Federal Match)
State Medicaid officials submit application
Must indicate cost neutrality
May require pressure to be processed
Most difficult way to obtain funding
Most sustainable

15. Medicaid Funding for Respite
The Medicaid Program
Strategies for Funding
Illinois’ Effort
Updates from other states

16. Illinois’ (long term) Medicaid Plan
Describe a bundle of services called respite
Ask IL Medicaid to pay a per-diem rate to cover these services (based on hospice model)
Apply for an 1115 waiver for Federal match
If successful, we hope this will be a model for other states
Challenge: Medicaid budget crisis

17. Medicaid Funding for Respite
The Medicaid Program
Strategies for Funding
Illinois’ Effort
Updates from other states

18. Updates from other States

19. Resources
“Advocates Guide to the Medicaid Program” – National Health Law Program (NHeLP)
“Medicaid in Supportive Housing: Lessons for Policy-Makers” - Corporation for Supportive Housing
Other respite providers

20. Questions and Discussion

21. Targeted Case Management Option
Coverage for assessment, goal setting, & linkages
Generally target high risk groups
Children
People with Developmental Disabilities
Uniquely defined “high risk groups”
Some programs are intended to be time limited
Each state’s program is unique

22. Waiver Types Home and Community Based Care Waivers
Programs keep people out of nursing homes / hospitals
Long term primary care
No Room and Board Charges Allowed
Freedom of Choice Waivers (1915B)
Programs save money by managing care
Often include long term case management
Research and Demonstration Projects (1115)

23. Research & Demonstration Project 1115 Waivers
Tests promising programs
Most waivers are for 5 years
Programs are evaluated by CMS
Must document cost neutrality
Can lead to Medicaid Law changes
PACE program
Most difficult type of waiver to obtain